Mental Status Exam (MSE)

The Mental Status Exam (MSE) is the psychological (equivalent of a physical exam) that
describes the mental state and behaviors of the person being seen and evaluates both the
objective observations of the clinician and subjective descriptions given by the patient.

1. It is an assessment of current mental capacity through It is one part of a full neurologic

(nervous system) examination.
2. The purpose of a MSE is to assess the presence and extent of a person’s mental impairment.
3. The MSE is an important part of the differential diagnosis of dementia and other psychiatric
symptoms or disorders.
4. A Mental Status Exam provides a snap shot at a point in time. So, it has to be done
frequently to know the progress of the treatment. MSE can also be given repeatedly to
monitor or document changes in a patient’s condition.

In such situations, specific questions and methods to assess the

- patient's appearance and
- general behavior, motor activity,
- speech, thought process, thought content and stream,
- mood and affect, perceptual disturbances, sensorium and cognition,
- general intellectual level; mathematical ability; and reasoning or problem-solving ability
- judgment and insight serve to identify features of various psychiatric illnesses.

The psychologist must pay close attention to the following regarding the patient: Components
of the Mental Status Exam: Appearance, Behavior, Speech, Mood, Affect, Thought process,
Thought content, Cognition, Insight/Judgment

The length of time required: for a Mental Status Examination depends on the patient’s
condition. It may take as little as five minutes to examine a healthy person. Patients with
speech problems or intellectual impairments, dementia, or other organic brain disorders may
require fifteen or twenty minutes. The examiner may choose to spend more time on certain
portions of the MSE and less time on others, depending on the patient’s condition and answers.

After the Mental Status Examination is over, record the entire thing in detail. Then take up the
interview with the family member or members who have accompanied the patient

Limitation: The MSE cannot be given to a patient who • cannot pay attention to the examiner,
for example, as a result of being in a coma or being unconscious; or • is completely unable to
speak (aphasic); or • is not fluent in the language of the examiner

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 MSE QUESTIONS
--- APPEARANCE: What do you see?
1. Build,
2. posture: 1. Small/tall/lean/ obese/ scrawny
3. Dress- 2. slouchy/sitting on edge/lean backwards
4. Grooming /unkempt, 3. normal, overdressed, improper, any peculiarities
5. Psychomotor activities – Psychomotor 4. hair Combing, and nails
learning is the relationship between 5. Coordinated physical activity using arms, hands,
cognitive functions and physical movement. fingers and feet and Hand-eye coordination increased,
Psychomotor learning is demonstrated by decreased, normal, retardation or agitation i.e.. making
physical skills such as movement, repetitive movements / Fidgeting/ tapping your foot or
coordination, manipulation, dexterity, grace, fingers repeatedly/ pacing./ switching channels on the
strength, speed—actions which remote repeatedly/ talking faster than normal/ hand
demonstrate the fine or gross motor skills, wringing,
such as use of precision instruments or
tools, and walking. Note psychomotor
retardation or generalized slowing of body
movements. Describe any aimless,
purposeless activity

6. Abnormal involuntary Movements:

6 tics, tremors, akathisia, restlessness/ill at ease
Restlessness, Excitement, overactive, Compulsive acts,
rituals or habits(e.g.; nail biting), sterotypies, gait,
Mannerisms
7. Catatonic features: psycho-motor
immobility and behavioural abnormality 7. Stupor / Lack of verbal response/ Mutism/ Rigid body
manifested by stupor posture/ Echolalia (repetition of another person's spoken
words)/ Echopraxia (involuntary repetition of another
person's actions)/ Agitation /
8. Neurotic appearance: fear, anxiety
8.Signs of anxiety are noted: moist hands, perspiring
forehead, tense posture, wide eyes. nail biting, Polydipsia
(a compulsion to drink water), plucking hair
9. Prominent physical abnormalities-
10.Level of alertness: 9. old looking, young looking, disheveled, childlike, issues in
11. Facial expression(Emotional) eye, nose/cleft lip/ squint / divergent or convergent eyes
/Hearing/ Vision.
12.Marks on skin / tattoos
13. PICCLE

10. Depressed, attentive

11. Crying, happy cheerful sad stoic shy timid fearful
tearful, open and widened

13.PALLOR: bloodlessness, ICTERUS: yellowish/pale eyes,

CYANOSIS looking bluish or black-bluish, CLUBBING of
finger nails, Lymphadenopathy- lymph nodes, EDEMA:
fitting edema.

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...... BEHAVIOR ------
Personality is the dynamic organization of uncooperative Attitude and Interpersonal Style :
those psychophysical systems that determine ingratiating, evasive, guarded, hostile, belligerent,
the characteristics behavior and thought to contemptuous, seductive, demanding, sullen, passive,
adjust to his environment. Behavior in manipulative, complaining, suspicious, guarded,
psychology consists of an organism's external withdrawn, or obsequious
reactions to its environment. Behavior with
examiner:
1. Eye contact with examiner: ex. poor,
good, piercing
2. Attitude toward the examiner:
Cooperative, You may find it cooperative,
friendly, attentive, interested, frank,
playful, intact/impaired(partially/fully)
3. Comprehension: working and empathic relationship
4. Rapport:
----- CONSCIOUSNESS-------- 1. Clear,
Consciousness refers to your individual 2. Drowsy: Sleepy
awareness of your unique thoughts, 3. Confused: do not respond quickly with information about their
memories, feelings, sensations, and name, location, and the time

environment. Your conscious experiences are 4. Delirium: Disoriented; restlessness, hallucinations, sometimes
delusions
constantly shifting and changing. 5. Obtundation: The person is difficult to arouse and
Level of consciousness (LOC) is a needs constant stimulation to stay awake
measurement of a person's arousability and 6. Stupor: Those who are not able to be aroused from a sleep-like
responsiveness to stimuli from the state
environment. 7. Coma: inability to make any purposeful response

------ SPEECH ------

• Speech is (ir)relevant, (in)coherent,
• Speech Rate: increased/pressured,
decreased/ monosyllabic, latency
• Speech Rhythm: articulation, prosody,
dysarthria, monotone, slurred,
neologisms, Echolalia, dysphasia, dysarthia,
• Speech Volume: loud, soft, mute
• length of answers to questions,
• Clarity of the answers
• Speech Content: fluent, loquacious, paucity,
impoverished, flight of ideas,
circumstantialities, loosining,
--------THOUGHT disorders-----
Idea is defined as "the reproduction with a more or less adequate image, of an object not actually present
to the senses."
Thought encompasses an "aim-oriented flow of ideas and associations that can lead to a reality-oriented
conclusion Three types of thoughts that our brains produce are 1) insightful (used for problem solving), 2)
experiential (focused on the task at hand), and 3) incessant (chatter).
THINKING is a mental behavior and process of brain wherein ideas, pictures, cognitive symbolizations, or
other hypothetical components of thought are experienced or manipulated.(interpreting desirable one)
1. Concrete thinking- if not? Negative thinking... depression, mentally ill
2. Abstract thinking- if not? Positive thinking...Flexible, easy to change
It impacts motivation, confidence

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THOUGHT DISORDER: is disturbance in thought process - Irrelevant detail, repeated words and phrases,
interrupted thinking (thought blocking), and loose, illogical connections between thoughts, may be signs of a
thought disorder manifested the way one put forth his ideas/ as evidenced by disorganized speech.

Psychiatrists consider formal thought disorder ("form") as being one of two types of disordered thinking,
with the other type being delusions. ("content"). In considering whether an individual has thought disorder,
patterns of their speech are closely observed.
https://www.slideshare.net/dima_ebrahim/form-of-thought-disorders
https://www.slideshare.net/drprashant24/disorders-of-thought-15266258
https://slideplayer.com/slide/6939770/
Disorders of Thought Screams: progression or Abnormal thought process: associations are not clear,
flow of thoughts organized, coherent.
1. Disorders of thought tempo (speed, rate) • Perseveration: Repetition of words, phrases or ideas
 flight of ideas – manic • Neologism
 slowing of thinking • Incoherence/ Word Salad: Randomly spoken words
 Circumstantialities • Loosening of association: Illogical shifting between
 tangentiality unrelated topics
2. Disorders of continuity of thought •Flight of ideas: Quickly moving from one idea to another-
 Perseveration see with mania
 Thought blocking • Circumstantial: provide unnecessary detail but
eventually get to the point
, illogicality, incoherence, loose associations, • Tangential: Move from thought to thought that relate in
some way but never get to the point
• Thought blocking: thoughts are interrupted
Disorders of Thought possession: To find out about the obsessions, the questions to be
• Preoccupations: are primary focus of the asked include the following:
patient's thinking • These actions can be repetitive and ritualistic, such as
checking the stove, counting steps, and straightening
• Obsessive ideas The patient experience picture frames
involuntary obsessional thoughts, images, or • Do you feel that a particular thought keep coming to
unpleasant ideas that are egodystonic your mind again and again despite your not wanting it?
• Do you feel sometimes a strange idea or feeling which
Thought alienation you think is not correct and however much you try the
thought does not go?
• Somatic preoccupation: hypochondriachal • Do you find sometimes an impulse to keep washing your
quality to the preoccupation. hands or other things at home even though you know it is
unwarranted?

• Do you feel Suicidal or homicidal ideation (SI or HI),

• Phobias: These are "irrational, intense, perseverations, obsessions or compulsions
persistent fears" of such items as dogs, Did you save 3 months' worth of medication for an
heights, elevators, insects, leaving home, overdose
closed spaces, and flying Have you purchased a gun
The three behaviors to look for in childhood are setting
Suicidality and Homocidality. fires, cruelty to animals, and bedwetting.
Discover if there are plans to carry out these
ideas
Disorders of Thought Content: Abnormal thought content
Refers to the themes that occupy the patient’s
thoughts and perceptual disturbances.

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Disorders of thought content Examples
include preoccupations, illusions, ideas of
reference, hallucinations, Intrusive
thoughts (altered thought content).
derealisation, depersonalization, delusions
• Illusions: The person either misperceives or
misinterprets a sensory stimulus.
• Dissociation: Dissociation refers to the To test for Dissociation:
splitting off of certain memories or mental • What is your name? • Who are you? • What work do you
processes from conscious awareness. do?
Dissociative symptoms include feelings of • Do you sometimes feel that you do not know who you
unreality, depersonalization, and confusion are?
about one’s identity. Depersonalization:
Sensation of unreality and abnormality
concerning oneself or parts of oneself
(dissociative experiences) • Derealisation:
Feelings the outer environment feels unreal
• Hallucinations: To test for hallucination the question to be asked is:
In the absence of external stimuli, the person • Do you sometimes hear some voice telling you to do
perceives something. something or not to do something?
False sensory perceptions. Can be auditory • Is there a command for the person to do something?
(AH), visual (VH), tactile or olfactory • Do you sometimes hear some voice when no one is
present?
• Do you feel that someone is talking about you and loudly
saying whatever you are doing?
find out who is talking, what they are saying, and how the
person feels about it.
• Delusions: To test for delusions the questions to be asked are
Fixed & persistent false beliefs firmly held in
spite of contradictory evidence. • Do you sometimes feel that people are after you?
1. Primary delusions • Do you sometimes feel that people are talking about
2. Secondary delusions you?
Content of delusions • Do you sometimes feel that your phone is tapped?
• Control: outside forces are controlling actions • Do you sometimes feel people are overhearing your
• Erotomanic: a person, usually of higher status, conversation?
is in love with the patient
• Grandiose: inflated sense of self-worth, power
or wealth
• Somatic: patient has a physical defect
• Persecutory: others are trying to cause harm
• Ideas of Reference (IOR): isinterpretation of
incidents and events in the outside world having
direct personal reference to the patient
• infidelity, love, ill-health, guilt, nihilistic,
poverty
The reality of delusions
Thought form disorders are: Thought Derailment, substitutions, & omissioins
Process/Form: Describes the rate of thoughts, Drivelling thinking
how they flow and are connected. Thought Desultory thinking
process refers to the logical connections
between thoughts and their relevance to the

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main thread of conversation.
• Normal: tight, logical and linear, coherent
and goal directed spontaneous, logical
• Abnormal: associations are not clear,
organized, and coherent. Examples: loose,
word salad, clanging
--------- MOOD DISORDERS ------- • Type: euthymic (normal mood), dysphoric (depressed,
Affect is a concept used in psychology to irritable, angry), euphoric (elevated, elated) anxious
describe the experience of feeling or emotion, • Range: full (normal) vs. restricted, blunted or flat, labile
the word "affect" as a noun being seldom • Congruency: does it match the mood- (mood congruent
used in other fields. Affect refers to the vs. mood incongruent)
underlying flow of moods. This would be the • Stability: stable vs. Labile
observable outward expression of the
emotional state. • Broad: Normal range of moods
• Appropriate: Appropriate to the situation
The word also refers sometimes to affect • Constricted: Restricted range of emotional expression
display, which is "a facial, vocal, or gestural • Blunted: Even more restricted
behavior that serves as an indicator of affect". • Flat: No change of mood, unemotional
In MSE, It may include either a lack of • Labile: Rapid change in mood (crying, then laughing)
emotional response to an event or an • Anhedonic: Incapable of any pleasurable
overreaction. response, depressed
Feeling,
in psychology, the perception of events within
the body, closely related to emotion.
Emotion, Constricted: Restricted range of emotional expression
in psychology is often defined as a complex Blunted affect: Always note a blunted affect where you
state of feeling that results in physical and find no change in mood throughout the interview and no
psychological changes that influence thought change in facial expression. It generally indicates
and behavior. According to author David G. depression
Meyers, human emotion involves." Emotional withdrawal: Always note if the person seems
Physiological arousal, expressive behaviors, emotionally withdrawn to you. The person would be
and conscious experience." inexpressive.
Full range of affect: This refers to an appropriate affective
response to the entire interview
Mood
in psychology is an emotional state. In contrast to emotions, feelings, or affects, moods are _less specific,
less intense and less likely to be provoked or instantiated by a particular stimulus or event. Mood is defined
as a pervasive and sustained emotion that colors the person's perception of the world
Mood disorders inconsistent with your circumstances include - Disruptive mood, Depressive mood, Maniac
mood, Cyclothymic disorder, bipolar disorder.
Mania, is a mood disorder that is characterized by sustained periods of mental and physical hyperactivity,
disorganization of behavior, abnormally elevated or irritable mood, intense energy, racing thoughts, and
other extreme and exaggerated behaviors. (a phase of bipolar disorder). Euphoric mania is just like it
sounds- people describe it as wonderful, beautiful, unbelievable, fantastic and expansive. Dysphoric
mania (a combination of mania and agitated depression that is also known as mixed mania) is the opposite
of euphoric mania.
Depression, in psychology, a mood or emotional state that is marked by feelings of low self-worth or guilt
and a reduced ability to enjoy life

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In MSE, Mood refers to the underlying Observe the patients’ mood during the interview and also
emotional “atmosphere” or tone of the ask how they are feeling. Statements about the patient's
person’s answers. Whether the person is in a mood should include depth, intensity, duration, and
sad mood, happy mood, angry mood etc. fluctuations
Mood is the prevalent emotional state the (1) Objectively (affect): your impression (appropriate
patient tells you they feel. Often placed in /inappropriate) – depressed, Elated, euthymic, blunted or
quotes since it is what the patient tells you flattened, anxious.
Examples “Fantastic, elated, depressed, (2) subjectively: how the patient reports prevailing mood –
anxious, sad, angry, irritable, good” depressed, elated.

1. Anxiety, irritability, suspicious,

2. (in)appropriate, (in)congruent
3. depressed, elation,
4. excessive displays

-------- COGNITIVE DISORDERS -----

Cognition is a term referring to the mental processes involved in gaining knowledge and comprehension.
These processes include thinking, knowing, remembering, judging and problem-solving. These are higher-
level functions of the brain and encompass language, imagination, perception, and planning. Cognition
refers to the act or condition of knowing.
Mini-Mental State Exam of 30 item screening tool. Useful for documenting serial cognitive changes an
cognitive impairment • level of consciousness, • Attention and concentration: the ability to focus, sustain
and appropriately shift mental attention, • Memory: immediate, short and long term; • Abstraction:
proverb interpretation.
Attention & concentration: test Attention: If the client is not focused on the
is the behavioral and cognitive process of interview, you can use digit repetition. Say five numbers,
selectively concentrating on a discrete aspect and then ask the person to recite them back to you
of information, whether deemed subjective or
objective, while ignoring other perceivable test concentration: by asking the person to perform a
information. Attention has also been complex mental task. (Serial 7s is one way of testing; in this
described as the allocation of limited cognitive method, you ask the person to add in increments of 7 or
processing resources. subtract from 100 by 7s
Perception: • Illusions: The person either misperceives or misinterprets
defined as a process by which individuals a sensory stimulus.
organize and interpret their sensory
impressions in order to understand stimuli
meaningfully to its environment.”
PERCEPTUAL DISORDERS --- See in THOUGHT
CONTENT DISORDERS
Orientation ask who are you and what your name is?) (age, birth date,
is often assessed as part of a mental status name
test to evaluate cognitive functioning and
screen for dementia. It refers to a person's ask the person where are you now?) ask home address,
level of awareness of the present city or state, or for directions from here
1. Person (ability to locate himself or herself)
2. time,
3. place and with regard to time (ask the person what time is it now?)
4. situation Ask for current date:

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Memory First, ask the person if she has been having any problems
is the means by which we draw on our past with memory
experiences in order to use this information in Short term/ recent memory: - A) ask the person what he
the present' (Sternberg, 1999). Memory is the had for breakfast, where she parked the car
term given to the structures and processes Immediate recall: limited to about seven items. Use a
involved in the storage and subsequent random list of digits. Ask the person to repeat them. Start
retrieval of information. Without memory, we with two digits and keep adding until the person fails, you
could not learn anything. might give three or four unrelated words
Immediate recall If the person fails at five
digits or less, there is reason for concern To test long term memory, tell me the name of the school
about sustained effort, attention span, and in which you studied.)
immediate memory
1. Recent memory
2. Remote memory
3. Immediate recall
Information and Intelligence • What is the capital of the state (or the country, or
includes the ability to benefit by applying France)?
knowledge, past experience logically and act • Who were the last four presidents?
purposefully to solve problems, and adapt to • Who is the governor of the state?
new situations. Intelligence can also be
defined as “the ability that intelligence tests • How many weeks are there in a year?
measure. • Who was Mark Twain?
1. Social ability
2. Political ability
3. Numerical ability
4. Mental balance
5. Ability to Abstract and Generalise
Ability to Abstract and Generalize
Numerical ability simple arithmetic-counting backward by threes or sevens
Ability to name specified objects and read or Show some objects and ask the person to name the same.
write complete sentences Show simple sentences and ask the person to read or write
the same.
Ability to understand and perform a task showing the examiner how to comb one’s hair or throw a
ball
Abstract think Ability to think abstractly ask to explain a proverb: • A
stitch in time saves nine. • A rolling stone gathers no
moss. • Don't judge a book by its cover. • Two wrongs
don't make a right

Similarities and Differences. Ask the person to tell you

how two objects or two events are different or alike. •
Apples and oranges • Trees and flowers • Houses and cars
• Dogs and cats

Ability to draw a simple map or copy a design draw a design like square or a triangle and ask the person
or geometrical figure to draw it after you.
Ability to distinguish between right and left touch the person’s left hand and ask what hand is it?
Repeat the same thing with the right hand.

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Judgement 1) ask the person what he would do if he or she
is a term that refers to the process by which finds a sealed envelope on the road).
people make decisions and form conclusions 2) what he or she would do about a commonsense
based on available information and material problem, such as running out of a prescription
combined with mental activity (thought) and medication
experience. Final decision which is acceptable, "Assess whether clients are able to understand the
and followed. potential consequences in their behavior" and can plan
preventive measures.
Judgment in MSE the ability to anticipate the
consequences of one’s behavior and make
decisions to safeguard your well being and
that of others
1. Testable judgement
2. Personal judgement- protect self & others
3. Social judgement:appropriate, inappropriat

Insight In psychology, occurs when a solution 1) do you think you are ill?
to a problem presents itself quickly and (If the person says he or she is not ill and that the
without warning. It is the sudden discovery of family member who has brought him or her is ill, that
the correct solution following incorrect shows lack of insight)
attempts based on trial and error. Insightful
thinking helps us to do long range planning 6 levels of insight follows:
and problem solving.
1. Complete denial of illness
Insight in MSE: Insight refers to a person’s 2. Partial denial of illness: Slight awareness of being sick
ability to recognize a problem and understand and needing help, but denying it at the same time
its nature and severity. It is self awareness of 3. Awareness of being sick but blaming it on others, on
one’s own illness and/or situation. external factors, or on organic factors
4. Partial Intellectual insight Awareness that illness is
caused by something unknown in the patient but don’t
want treatment
5.Intellectual insight: admission that the patient is ill and
that symptoms or failures in social adjustment are caused
by the patient's own particular irrational feelings or
disturbances without applying this knowledge to future
experiences
6. True emotional insight: emotional awareness of the
motives and feelings within the patient and the important
persons in his or her life, which can lead to basic changes in
behavior. Ready for treatment

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=======EXAMPLE=======
Sample initial MSE of a patient with depression and psychotic features
• Appearance: Disheveled, somnolent, slouched down in chair, uncooperative
• Behavior: psychomotor retarded, poor eye contact
• Speech: moderate latency, soft, slow with paucity of content
• Mood: ”really down“
• Affect: blunted, mood congruent
• Thought Process: linear and goal directed with paucity of content
• Thought Content: +SI, +AH, +paranoia, -VH, -IOR, -HI
• Cognition: Alert, focused,
MMSE:24- missed recall of 2 objects, 2 orientation questions, 2 on serial sevens
• Insight: fair
• Judgment: poor

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